Provider Demographics
NPI:1740333574
Name:HALE, CAROLYN I (MD)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:I
Last Name:HALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 INLAND SHORES WAY N STE 202
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-3884
Mailing Address - Country:US
Mailing Address - Phone:503-463-6799
Mailing Address - Fax:
Practice Address - Street 1:5900 INLAND SHORES WAY N STE 202
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-3884
Practice Address - Country:US
Practice Address - Phone:503-463-6799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10836174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR02557Medicaid
ORC04239Medicare UPIN
OR02557Medicaid